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If these responded to erectile dysfunction young adults cheap 30mg dapoxetine free shipping primary care treatments are unsuccessful many patients will respond management injections for erectile dysfunction forum discount 60 mg dapoxetine overnight delivery. Note: Symptomatic haemorrhoids found as part of colonoscopy investigation can be banded if patient fully consented for the procedure impotence at 19 order generic dapoxetine line, and this is included within the original costs erectile dysfunction treatment new orleans buy dapoxetine once a day, i. Clinicians can submit an individual funding request outside of this guidance if they feel there is a good case for clinical exceptionality. Policy Exclusions Any perianal lesion or episodes of perianal bleeding that are suspected of being due to malignancy are excluded from this policy and should be referred via the normal 2-week pathway. We propose Referrals for the treatment of chalazia be removed only according to the criteria listed Eyelid Lesions (Removal of common benign eyelid lesions in Appendix 2. To be worse pain is experienced clear, ‘pure subacromial shoulder impingement’ means for some time after the subacromial pain not caused by associated diagnoses procedure and such as rotator cuff tears, acromio-clavicular joint pain, rehabilitative or calcific tendinopathy. Non-operative treatment such physiotherapy is required as physiotherapy and exercise programmes are to improve function to the effective and safe in many cases. This may symptoms, in spite of adequate non-operative mean that you are unable treatment, surgery should be considered. The latest to work or undertake evidence for the potential benefits and risks of routine chores for up to 3 subacromial shoulder decompression surgery should months. Risk of serious be discussed with the patient and a shared decision complication is very low. Surgery should be considered for persistent prior to the following: severe symptoms. We are proposing that surgical Carpal Tunnel Syndrome Try corticosteroid injections if: treatment of carpal tunnel is only offered under the (Surgical Interventions for) • there was no improvement with criteria included at Appendix 2 and would like to seek 3 months of conservative views on the proposed criteria as part of this treatment consultation. If this is not available in There is insufficient detail in the criteria to ensure the primary care, then the patient appropriate haemorrhoids are treated and or so funding should be referred to secondary can be agreed at screening. It found that after 3 to 5 Contracture Contracture depends on the release years, the problem had returned in about half of the Dupuytren’s Contracture stage of the disease. We propose that surgery is only Dupuytren’s can be classified as offered according to the criteria outlined in Appendix 2. Appendix 2 Mild Surgery should be avoided in cases where there is no • No functional problems contracture, and in patients with a mild contracture that is not progressing and does not impair function. Moderate Functional problems with For further information, please see: activities of daily living as a direct fi. Recurrent Disease Recurrent disease may be treated in line with the above classification as for new disease. Surgery excision can cause complications, and recurrence is Reference: is only commissioned for common following surgery. The complications may be ganglion of the flexor tendon similar to or worse than the original problem. If there is diagnostic uncertainty after diagnostic tests Moderate have been performed. Severe fi severe pain fi restriction of activities of daily living fi concern over the diagnosis Treatment: As most ganglion will resolve spontaneously and as a high proportion will recur after surgery the routine treatment for all should be reassurance and observation, with aspiration in primary care for reassurance. We are proposing Finger managed as follows before that surgery is only offered in specific cases where referral for surgical intervention: alternative measures have not been successful and Trigger Finger (Surgical • They have been given and persistent or recurrent triggering, or a locked finger Correction of) followed advice on avoiding occurs. We would like to seek views on the proposed activities that cause pain, criteria in Appendix 2 as part of this consultation. Appendix: • They have used a small splint Surgery should be only performed in specific cases to hold the finger or thumb where alternative measures have not been successful. The risks of injection are small (it very occasionally causes some thinning or colour change in the skin at the site of injection). If clinically appropriate, the patient may be offered a second injection at the discretion of the treating clinician. Treatments like historic restrictions and • They are bleeding from a endothermal ablation or ultrasound-guided foam were agreed after a varicosity. The history is largely from a source other than the patient, and the examination requires patience and talent. There are several tricks to make the visit go as smoothly and efficiently as possible (see the box on the following page). The old adage that “the patient is always right” is especially true in the case of parents’ observations about their children. Most of the history is obtained from the parents or the referring physi cian, but any input from the child is equally important. Many children will not complain of blurry vision or diplopia, but should they describe these symptoms one must be very alert to an acute process. This is also an invaluable time to observe the child in an unobtrusive fashion and preliminarily assess head position, eye alignment, and overall appearance. Often this may be the extent of the physical examination that one can obtain; once children realize that attention is focused on them, they may become very uncooperative. The problem precipitating the visit should be stated in the parents’ or child’s own words and then elaborated. Requisite 1 2 handbook of pediatric strabismus and amblyopia questioning for all pediatric eye problems should clarify whether the problem is congenital or acquired and should specify the age of onset in the latter case. If the chief complaint is a visual problem, it is helpful for the parents to specify what the child can or cannot see; that is, does the child respond to lights, faces, toys near or far, very small itemsfi In cases of strabismus, the fre quency and stability of the deviation and any associated head posture are important. Precipitating factors may include fatigue, illness, sunlight, and close or distance work. With cataracts, any history of trauma, medications, or associated medical conditions is important, as well as the family history. Tearing patients need to be questioned about any redness, pho tophobia, or crusting of the lashes. In ptosis, the stability or vari ability is important, as is any associated chin elevation or general neuromuscular problems. For difficulties in school, it is helpful to determine if the problem is only visual or is related to a par ticular subject area (reading, spelling, writing, or math) and if there are any stress factors in the child’s extracurricular life. Important aspects of past history include prenatal and peri natal problems, birth weight, gestational age, and mode of deliv ery. Any medical problems should be elicited, as well as current medication and allergies. Early development should be assessed by asking about specific developmental milestones, such as rolling over, sitting up, and walking. The family history is very important because often the young child does not have enough past history to be useful. The focus should be on the presence of strabismus, poor vision, and neuro logical problems. In the case of possible genetic disorders, the number and sex of siblings, possible consanguinity, and the number and gestational age of any miscarriages should be documented. Children can be unpredictable, noncommunicative, and uncooperative, which chapter 1: pediatric eye examination 3 may make the examination both time consuming and frustrat ing for a busy practitioner. However, if extra time is taken ini tially to gain the trust of the child, the rest of the exam will go much more easily. This “friendship” is often first established in the waiting room, where toys, appropriate books, and even small furniture should be made available. In a general prac tice seeing children on a fairly regular basis, at least one exam room should be outfitted to make a child feel relaxed and make the exam go more smoothly. A 20-foot lane is best because of the frequent use of single Allen cards and the need for distance measurements in strabismus. Attention-getting distance targets may include a remote control cartoon movie or a motorized animal. Near targets should have variety and appeal, as one frequently finds that “one toy–one look” is the rule. Approach young children as though you had come to play with and entertain them, and you will receive a lot of useful information in the process.


  • Triopia
  • Ochronosis
  • Battaglia Neri syndrome
  • Hypertrichosis lanuginosa congenita
  • Diabetes mellitus type 1
  • Hypoplastic left heart syndrome
  • Idiopathic edema
  • Refsum disease
  • Chromosome 13q trisomy

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Iris stop designed to erectile dysfunction surgery order 60mg dapoxetine free shipping grasp the membrane without grasping iris or other ocular structures 60784 impotence of organic origin 90mg dapoxetine for sale. The forceps platforms at the tip provide secure grasp at the tip and a platform at the rear of the forceps arms provide a mechanical stop erectile dysfunction studies purchase dapoxetine 90mg otc. E3190 x 1 Katzin-Barraquer Corneal Forceps 7 mm tying platform with 1 x 2 teeth 0 erectile dysfunction 18-25 order 90 mg dapoxetine fast delivery. Brown Nucleus Cracker Forceps A reverse action instrument with paddle tips to provide a solid surface to crack the nucleus when used in a scleral tunnel. The reverse action mechanism allows increased flexibility in positioning the instrument tips. E0740 x 1 Slade Vertical Nucleus Cracker Used in femtosecond laser cataract techniques. E0741 x 1 Slade Coaxial Chopper Designed for use in femtosecond laser cataract techniques. The Instrument features two 90° flat tips designed to assist in the separation of nuclear cracks. E2014 x 1 Implant Removal Forceps Designed to provide an excellent grasp of the lens optic or lens segment to efficiently remove from the anterior chamber. E2988 x 1 Thornton Implant Forceps Facilitates grasping and implanting the haptic loop beneath the pupil margin and within the capsular bag without wrist twisting. M iscellaneous E1946 x 1 Jewelers Type Forceps 3 mm crisscross serrated tying platforms. M osquito 77021 x 1 Halstead Straight Hemostatic Forceps Straight 20 mm serrated jaws. Retinal E5378 x 1 W atzke Sleeve Spreading Forceps Designed to spread silicone sleeves for circling bands. Less mass at the tip of the instrument allows for easier visualization of tissue and grasp of delicate membranes. Forceps Tip low glare titanium Rotatable Intraocular Thomas Subretinal low glare forceps Tip. This instrument provides a smaller delicate grasp of tissue and has less mass at the tip of the instrument which allows for easier visualization of tissue and grasp of delicate membranes. The asymmetric jaw is designed to allow the surgeon to see over the instrument to visualise retinal tissue. A smaller jaw provides better visualization of tissue and grasping ability of delicate tissue. Less mass at the tip of the instrument allows for easier visualisation of tissue and grasp of delicate membranes. The front half of this instrument is light blue to indicate an endgripping forceps. The dual function of the instrument is designed to create the ability to lift the membrane with the angled pic and then solidly grasp tissue with the platform. The front half of this instrument is violet to indicate an asymmetrical peeling forceps. The dual function of the instrument gives the ability to lift the membrane with the angled pic and then solidly grasp tissue with the platform. W ide endgripping tips for grasp of the membrane and a large window to provide visualization while peeling the membrane. W ide endgripping tips for grasp of the membrane and a large window to provide excellent visualization while peeling the membrane. E1817 S x 1 Lieberman Suturing Forceps Double toothed tips with 0,1 mm teeth spaced 1 mm apart. E1500 C x 1 Bishop-Harmon Curved Tissue Forceps Curved shafts with fine 1 x 2 teeth. E1790 x 1 W einstock Intraocular Tissue Forceps this serrated intraocular forceps is designed for use in microincisional surgery. This instrument may also be used for grasping iris or other tissues and for intraocular suturing. E1791 x 1 W einstock Intraocular Tying Forceps the smooth intraocular forceps is designed for use in microincisional surgery. The instrument may also be used as a needle driver or needle forceps for intraocular suturing. E1889 x 1 Paton Tying and Stich Removal Forceps Straight heavy shafts with delicate 7 mm tying platform. Also available as component of a custom made sterile single use Per Procedure Tray. The smooth irrigation and aspiration ports are designed to eliminate sharp edges for reduced risk of capsule rupture. Proprietary locking irrigating connector for use with the Stellaris System tubing kits. E0100 E x 1 Economy Diamond Knife, 45° Single edge 45 degree blade for performing side-port incision and scleral groove. E0102 M x 1 Angled Tunnel Blade Diamond Knife, 45° Economy Trifacet Diamond Knife. E0103 E x 1 Economy Trifacet Diamond Knife Diamond blade for scleral groove and tunnel incision. E0105 M x 1 Triple Edge Arcuate Diamond Knife 15° 15 degree thin blade designed for all corneal incisions. E0118 x 1 Brown Tri-facet Diamond Knife Universal trifacet shaped diamond blade provides excellent control when used in a sweeping motion during scleral tunneling. It allows creation of watertight incisions while producing minimal corneal distortion. The very small footplate is curved to conform to the fixation/degree gauge and provides a guide for making the arcuate incision at the limbus. A micrometer handle is designed for use with nomograms that require depth adjustment based on pachymetry. Handle designed for finger twirling as blade follows arcuate pattern of the limbus. It also allows easier creation of watertight incisions while producing less corneal distortion. Unique, blunt dolphin nosed tip designed to follow the slit blade incision easily while the cutting edges create a precise opening for lens insertion. Non-reflective surface improves visibility by reducing microscope light source glare. E7599 x 6 2 Laseredge™ Clear Corneal Knife this blade is designed to produce an internal incision width of 1. E0569 x 1 O‘Gawa Lens Dialer Excellent for manipulation of the intraocular lens in the capsular bag. The angled and curved shaft allows the instrument to reach across the implant and catch the optic/haptic junction to facilitate dialing the lens. The manipulator is used in conjunction with the phaco tip to separate the nucleus in a “Quik-Chop” technique developed by Dr. The double-ended instrument has a nucleus chopper at one end combined with a mini Barrett mushroom tip on the opposite end for manipulation of iris. E0629 x 1 Drysdale Nucleus Manipulator Flattened paddle tip with generous surface area is ideal for manipulating tissue, rotating and cracking the nucleus. E4933 x 1 Barrett Micro Mushroom Manipulator Ideal for nucleus manipulation during phacoemulsification. E0570 N x 1 Nichamin Double Ended Spatula Chopper W edge-shaped chopper designed to allow nucleus chopping in three directions. E0576 M x 1 Minami „M“ Hook this teardrop-shaped tip with multi-angled shaft is ideal for the „Miracle Multiple-Cut“ technique and is used for dividing and manipulating nucleus material from all directions in the capsule. E0590 x 1 Seibel Ambidextrous Chopper Olive tip on instrument is designed to provide safety for the posterior capsule. E0641 x 1 Silverstein Phaco Manipulator & Quick Chop this universal slimmed profile crystalline lens manipulator benefits from a chopper on one end.

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Mortality and morbidity statistics should be coded according to erectile dysfunction natural remedies over the counter herbs generic 30mg dapoxetine otc the Tabular list of inclusions and the Alphabetical index erectile dysfunction treatment in kuwait buy cheap dapoxetine 60 mg line. When information on birth weight is unavailable erectile dysfunction drugs in development best order for dapoxetine, the corresponding criteria for gestational age (22 completed weeks) or body length (25 cm crown–heel) should be used erectile dysfunction statistics 2014 buy dapoxetine australia. The criteria for deciding whether an event has taken place within the perinatal period should be applied in the order: (1) birth weight; (2) gestational age; (3) crown–heel length. In statistics for international comparison, inclusion of the extremely low-birth weight group disrupts the validity of comparisons and is not recommended. For the purpose of international reporting of maternal mortality, only those maternal deaths occurring before the end of the 42-day reference period should be included in the calculation of the various ratios and rates, although the recording of later deaths is useful for national analytical purposes. Deaths should preferably be classified by sex and age group, as in the recommendations in Section 5. For statistics of perinatal mortality, full-scale multiple-cause analysis of all conditions reported will be of greatest benefit. W here such analysis is impracticable, analysis of the main disease or condition in the fetus or infant, and of the main maternal condition affecting the fetus or infant, with cross-tabulation of groups of these two conditions, should be regarded as the minimum. Where it is necessary to select only one condition, the main disease or condition in the fetus or infant should be selected. Sauvages’ comprehensive treatise was published under the title Nosologia methodica. A contemporary of Sauvages was the great methodologist Linnaeus (1707–1778), one of whose treatises was entitled Genera morborum. At the beginning of the 19th century, the classification of disease in most general use was one by William Cullen (1710–1790), of Edinburgh, which was published in 1785 under the title Synopsis nosologiae methodicae. For all practical purposes, however, the statistical study of disease began a century earlier with the work of John Graunt on the London Bills of Mortality. The kind of classification envisaged by this pioneer is exemplified by his attempt to estimate the proportion of liveborn children who died before reaching the age of six years, no records of age at death being available. He took all deaths classed as thrush, convulsions, rickets, teeth and worms, abortives, chrysomes, infants, livergrown, and overlaid and added to them half the deaths classed as smallpox, swinepox, measles, and worms without convulsions. Despite the crudity of this classification his estimate of a 36% mortality before the age of 6 years appears from later evidence to have been a good one. While three centuries have contributed something to the scientific accuracy of disease classification, there are many who doubt the usefulness of attempts to compile statistics of disease, or even causes of death, because of the difficulties of classification. To these, one can quote Major Greenwood: “The scientific purist, who will wait for medical statistics until they are nosologically exact, is no wiser than Horace’s rustic waiting for the river to flow away” (30). Fortunately for the progress of preventive medicine, the General Register Office of England and Wales, at its inception in 1837, found in William Farr (1807–1883) – its first medical statistician – a man who not only made the best possible use of the imperfect classifications of disease available at the time, but laboured to secure better classifications and international uniformity in their use. It had not been revised to embody the advances of medical science, nor was it deemed by him to be satisfactory for statistical purposes. In the first Annual Report of the Registrar-General (31), therefore, he discussed the principles that should govern a statistical classification of disease and urged the adoption of a uniform classification as follows: the advantages of a uniform statistical nomenclature, however imperfect, are so obvious, that it is surprising no attention has been paid to its enforcement in Bills of Mortality. Each disease has, in many instances, been denoted by three or four terms, and each term has been applied to as many different diseases: vague, inconvenient names have been employed, or complications have been registered instead of primary diseases. The nomenclature is of as much importance in this department of inquiry as weights and measures in the physical sciences, and should be settled without delay. Both nomenclature and statistical classification received constant study and consideration by Farr in his annual ‘Letters’ to the Registrar-General published in the Annual Reports of the Registrar-General. The utility of a uniform classification of causes of death was so strongly recognized at the first International Statistical Congress, held in Brussels in 1853, that the Congress requested William Farr and Marc d’Espine, of Geneva, to prepare an internationally applicable, uniform classification of causes of death. At the next congress, in Paris in 1855, Farr and d’Espine submitted two separate lists, which were based on very different principles. Farr’s classification was arranged under five groups: epidemic diseases, constitutional (general) diseases, local diseases arranged according to anatomical site, developmental diseases and diseases that are the direct result of violence. In 1864, this classification was revised in Paris, on the basis of Farr’s model, and was subsequently further revised in 1874, 1880 and 1886. Although this classification was never universally accepted, the general arrangement proposed by Farr, including the principle of classifying diseases by anatomical site, survived as the basis of the International list of causes of death. It is of interest to note that Bertillon was the grandson of Achille Guillard, a noted botanist and statistician, who had introduced the resolution requesting Farr and d’Espine to prepare a uniform classification at the first International Statistical Congress in 1853. The classification prepared by Bertillon’s committee was based on the classification of causes of death used by the City of Paris, which, since its revision in 1885, represented a synthesis of English, German, and Swiss classifications. The classification was based on the principle, adopted by Farr, of distinguishing between general diseases and those localized to a particular organ or anatomical site. In accordance with the instructions of the Vienna Congress made at the suggestion of L Guillaume, the Director of the Federal Bureau of Statistics of Switzerland, Bertillon included three classifications: the first, an abridged classification of 44 titles; the second, a classification of 99 titles; and the third, a classification of 161 titles. The Bertillon classification of causes of death, as it was first called, received general approval and was adopted by several countries, as well as by many cities. The classification was first used in North America by Jesus E Monjaras, for the statistics of San Luis de Potosi, Mexico (32). In 1898, the American Public Health Association, at its meeting in Ottawa, Canada, recommended the adoption of the Bertillon classification by registrars of Canada, Mexico, and the United States of America. The Association further suggested that the classification should be revised every 10 years. At the meeting of the International Statistical Institute at Christiania in 1899, Bertillon presented a report on the progress of the classification, including the recommendations of the American Public Health Association for decennial revisions. The International Statistical Institute then adopted the following resolution (33): the International Statistical Institute, convinced of the necessity of using in the different countries comparable nomenclatures: Learns with pleasure of the adoption by all the statistical offices of North America, by some of those of South America, and by some in Europe, of the system of cause of death nomenclature presented in 1893; Insists vigorously that this system of nomenclature be adopted in principle and without revision, by all the statistical institutions of Europe; Approves, at least in its general lines, the system of decennial revision proposed by the American Public Health Association at its Ottawa session (1898); Urges the statistical offices who have not yet adhered, to do so without delay, and to contribute to the comparability of the cause of death nomenclature. A detailed classification of causes of death, consisting of 179 groups and an abridged classification of 35 groups, was adopted on 21 August 1900. The desirability of decennial revisions was recognized, and the French Government was requested to call the next meeting in 1910. In fact, the next conference was held in 1909, and the Government of France called succeeding conferences in 1920, 1929 and 1938. Bertillon continued to be the guiding force in the promotion of the International list of causes of death, and the revisions of 1900, 1910 and 1920 were carried out under his leadership. As Secretary-General of the International Conference, he sent out the provisional revision for 1920 to more than 500 people, asking for comments. At the 1923 session of the International Statistical Institute, Michel Huber, Bertillon’s successor in France, recognized this lack of leadership and introduced a resolution for the International Statistical Institute to renew its stand of 1893 in regard to the International classification of causes of death and to cooperate with other international organizations in preparation for subsequent revisions. The Health Organization of the League of Nations had also taken an active interest in vital statistics and appointed a Commission of Statistical Experts to study the classification of diseases and causes of death, as well as other problems in the field of medical statistics. E Roesle, Chief of the Medical Statistical Service of the German Health Bureau, and a member of the Commission of Expert Statisticians, prepared a monograph that listed the expansion in the rubrics of the 1920 International list of causes of death that would be required if the classification was to be used in the tabulation of statistics of morbidity. This careful study was published by the Health Organization of the League of Nations in 1928 (34). In order to coordinate the work of both agencies, an international commission, known as the ‘Mixed Commission’, was created with an equal number of representatives from the International Statistical Institute and the Health Organization of the League of Nations. This commission drafted the proposals for the Fourth (1929) and the Fifth (1938) revisions of the International list of causes of death. The conference approved three lists: a detailed list of 200 titles, an intermediate list of 87 titles and an abridged list of 44 titles. As regards classification of diseases for morbidity statistics, the conference recognized the growing need for a corresponding list of diseases to meet the statistical requirements of widely differing organizations, such as health insurance organizations, hospitals, military medical services, health administrations and similar bodies. International Lists of Diseases In view of the importance of the compilation of international lists of diseases corresponding to the international lists of causes of death: the Conference recommends that the Joint Committee appointed by the International Institute of Statistics and the Health Organization of the League of Nations undertake, as in 1929, the preparation of international lists of diseases, in conjunction with experts and representatives of the organizations specially concerned. Pending the compilation of international lists of diseases, the Conference recommends that the various national lists in use should, as far as possible, be brought into line with the detailed International List of Causes of Death (the numbers of the chapters, headings and subheadings in the said List being given in brackets). The conference further recommended that the Government of the United States of America continue its studies of the statistical treatment of joint causes of death, in the following resolution (35): 3. Farr, however, recognized that it was desirable “to extend the same system of nomenclature to diseases which, though not fatal, cause disability in the population, and now figure in the tables of the diseases of armies, navies, hospitals, prisons, lunatic asylums, public institutions of every kind, and sickness societies, as well as in the census of countries like Ireland, where the diseases of all the people are enumerated” (27). In his Report on nomenclature and statistical classification of diseases, presented to the Second International Statistical Congress, he therefore included in the general list of diseases most of those diseases that affect health, as well as diseases that are fatal. At the Fourth International Statistical Congress, held in London in 1860, Florence Nightingale urged the adoption of Farr’s classification of diseases for the tabulation of hospital morbidity in the paper, Proposals for a uniform plan of hospital statistics. At the First International Conference to Revise the Bertillon classification of causes of death in Paris in 1900, a parallel classification of diseases for use in statistics of sickness was adopted. The extra categories for non-fatal diseases were formed by subdivision of certain rubrics of the cause-of-death classification into two or three disease groups, each of which were designated by a letter.

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Review knowledge from previous levels Page 253 of 385 Trauma Chest Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to impotence pump buy dapoxetine in india formulate a field impression to erectile dysfunction quick natural remedies order 60mg dapoxetine free shipping implement a comprehensive treatment/disposition plan for an acutely injured patient impotence yoga pose cheap dapoxetine 60mg online. If chest wall hole is 2/3 size of trachea erectile dysfunction medication online buy discount dapoxetine 30mg line, more air will enter from the atmosphere – sucking sound will be present f. With large holes air enters both the trachea and the hole rapidly collapsing the lung g. Increased pleural pressure – shift of mediastinal structures to contralateral side – causes kinking of great veins decreasing cardiac output d. Knee – true emergency – position found unless distal circulation compromised, then anatomical alignment 8. Description – shearing force causes tissue to completely separated from base, and either lost or left with a flap. Burn extends into subcutaneous tissue possibly including bone and muscle tissue h. Special management considerations Page 277 of 385 Trauma Head, Facial, Neck, and Spine Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Le Fort I Fracture separates hard palate and lower maxilla from remainder of skill Page 278 of 385 b. The pressure causes the weakest area (orbital floor) to give way, causing herniation of orbital contents (inferior oblique muscle entrapment) into the maxillary sinus. Depressed skull fractures may require circumferential digital pressure to control an open skill fracture bleed 3. Attempt to listen to fetal heart tones – 4 o’clock position, about 2” from mother umbilicus Page 287 of 385 D. Autism – differences in social, communication and ability to purposefully shift attention (may become agitated with touch) B. Risk is high for young and elderly, patients who can not generate heat (diseases and medications) c. If cold continues, vasocontriction is lost and then vasodilation occurs with loss of core heat to the periphery f. Unbelted drivers and front seat passengers suffer multi-system trauma due to multiple collisions of the body and organs c. Typically a patient considered to have “multi-trauma” has more than one major system or organ involved a. Multi-trauma treatment will involve a team of physicians to treat the patient such as neurosurgeons, thoracic surgeons, and orthopedic surgeons 4. The definitive care for multi-system trauma is surgery which can not be done in the field b. Changes in vital signs or assessment findings while en route are critical to report and document 7. Newly licensed paramedics who have not seen many multi-system trauma patients need to stick with the basics of life saving techniques b. Multi-casualty care Page 301 of 385 Special Patient Population Obstetrics Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Bleeding Related to Pregnancy: pathophysiology, assessment, complications, management 1. Postpartum Complications: pathophysiology, assessment, complications, management 1. Post partum depression Page 306 of 385 Special Patient Population Neonatal Care Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Neonatal mortality risk can be determined via graphs based on birth weight and gestational age b. Complete airway obstruction a) Atelectasis b) right-to-left shunt across the foramen ovale ii. Risk factors - prolonged and frequent multiple seizures may result in metabolic changes and cardiopulmonary difficulties 2. Morbidity/ mortality - infants may die of cold exposure at temperatures adults find comfortable c. Erythema, abrasions, ecchymosis and subcutaneous fat necrosis can occur with forceps delivery iii. Properly placing an infant in “sniffing position” to open the airway may require a towel or roll under the shoulders d. In children younger than 10 years, narrowest part of the airway is below the vocal cords at the non-distensible cricoid cartilage 7. Because in children younger than 10 years, the narrowest part of the airway is below the vocal cords, uncuffed tubes are used v. Pneumothoraces and esophageal intubations are often missed due to the ease with which breath sounds are transmitted all over the thorax through the thin chest wall Page 327 of 385 D. Growth plates generally disappear 2 years after girls have their first periods; in boys it is usually by mid to late high school 5. Angle slightly away from the growth plate when inserting an intraosseous needle F. Hypothermia can limit resuscitative efforts and interfere with the body’s ability to clot properly G. When ventilating a pediatric patient, the bag should have no less than 450-500 mL volume c. Err on using a larger bag for ventilating the pediatric patient; regardless of the size of the bag used for ventilation, one should only use enough force to make the chest rise slightly to limit pneumothorax Page 328 of 385 d. Continually evolves throughout childhood allowing them to develop new abilities 2. The subarachnoid space is relatively smaller offering less cushioning to the brain 4. The large cerebral blood flow requirement makes children with head injuries extremely susceptible to hypoxia; hypoxia and hypotension in a child with a head injury can cause ongoing damage as bad as the initial injury itself b. Since the weaker neck supports a relatively heavier head and therefore flexes more easily with trauma, cervical spine injuries sustained are usually higher (C1-3) f. When in doubt about the presence of a cervical spine injury, assume the worst and maintain immobilization of the child’s head and neck I. Infants and children are prone to hypothermia due to increased body surface area 3. Make sure to cover the head (not the face, though) to minimize heat loss Page 329 of 385 c. Have a very low threshold for checking blood glucose levels, especially in children who are having a seizure or are lethargic on your exam d. When obvious reasons for crying have been addressed, persistent crying can be a sign of significant illness c. This is a particularly stressful time for parents adjusting to the eating, sleeping, and crying cycle; sometimes this is complicated by post-partum depression, too, which can be a risk factor for abuse. Infants of this age begin to identify and respond to facial expressions; approach them with a smile or funny face and a happy, soft spoken voice iv. Development of “separation anxiety” from their parents and the start of tantrums ii. With the increased mobility of crawling and walking comes exposure to physical dangers B. The front teeth come in before the molars, which means that children may bite off large pieces of food and then not be able to grind them up before swallowing, increasing the risk of food aspiration; do not give children exam gloves to play with iii. Separation anxiety is best dealt with by keeping the child and parent together as much as possible during evaluation and involving the parent in the treatment if appropriate; if possible, interact first with the parent to build trust with infant iv. As children begin to relate cause and effect, painful procedures make lasting impressions; be considerate by limiting painful procedures and adequately treating pain 3. Do not waste time trying to use logic to convince preschoolers; they are concrete thinkers,; avoid frightening or misleading comments vii. Children with chronic illness or disabilities begin to be very self-conscious iii. School aged children can understand simple explanations for illness and treatments iii. Relationships generally transition from mostly same sex ones to those with the opposite sex d. Physical findings (mental status, respiratory rate, pulse oximetry, capnometry, work of breathing, color, heart rate, degree of aeration, presence of stridor or wheeze) 4. Inhaled medicationsbronchodilators (albuterol, ipratropium, racemic epinephrine) v. Oral and intramuscular medications (prednisolone, dexamethasone)Corticosteroids vi.

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